Clinical research on behavioral activation as treatment for post‐traumatic stress disorder: A brief review and meta‐analysis

Behavioral activation (BA), an effective treatment for depression, has recently been receiving attention as a possible intervention for PTSD. BA interventions could be particularly useful in treating underserved populations (i.e., individuals with lower socioeconomic status). A literature search was conducted, which identified seven outcome studies that examined the effectiveness of stand‐alone BA treatment for individuals with PTSD. All studies identified for this brief review demonstrated clinically significant reductions in PTSD symptoms using BA as an intervention. A meta‐analysis of these few studies revealed a nonsignificant effect (Cohen's d = 0.713, p = .512) despite reporting an average symptom reduction of 25.8%. Other studies utilizing BA treatment for PTSD do so in tandem with other interventions and were excluded from analysis. This brief review summarizes the literature on the use of BA as a stand‐alone treatment for PTSD and suggests that future research seek to confirm the usefulness of BA as a potential treatment modality for mental health‐care providers treating individuals with PTSD.     

Predicting post‐traumatic growth and post‐traumatic stress in firefighters

Emergency service workers (e.g., firefighters, police, and paramedics) are exposed to elevated levels of potentially traumatising events through the course of their work. Such exposure can have lasting negative consequences (e.g., post‐traumatic stress disorder (PTSD)) and/or positive outcomes (e.g., post‐traumatic growth (PTG)). Research had implicated trauma, occupational and personal variables that account for variance in post‐trauma outcomes yet at this stage no research has investigated these factors and their relative influence on both PTSD and PTG in a single study. Based in Calhoun and Tedeschi's model of PTG and previous research, in this study regression models of PTG and PTSD symptoms among 218 firefighters were tested. Results indicated organisational factors predicted symptoms of PTSD, while there was partial support for the hypothesis that coping and social support would be predictors of PTG. Experiencing multiple sources of trauma, higher levels of organisational and operational stress, and utilising cognitive reappraisal coping were all significant predictors of PTSD symptoms. Increases in PTG were predicted by experiencing trauma from multiple sources and the use of self‐care coping. Results highlight the importance of organisational factors in the development of PTSD symptoms, and of individual factors for promoting PTG.     

Recovery from post‐traumatic stress disorder in children following road traffic accidents: the role of talking and feeling understood

Forty children were assessed 6 weeks and 8 months after involvement in a road traffic accident (RTA). Ten of the 21 children suffering post‐traumatic stress disorder (PTSD) at 6 weeks continued to fulfil diagnostic criteria at 8 months. There was no evidence of delayed onset of PTSD in children who had not developed this condition at 6 weeks. Talking about the accident and feeling understood were associated with recovery. Providing children with opportunities to talk about their accident may be helpful in preventing or reducing psychological distress. Copyright © 2001 John Wiley & Sons, Ltd.     

A thematic analysis of practitioners' understanding of domestic abuse in terms of post‐traumatic stress disorder (PTSD) and complex‐PTSD (C‐PTSD)

There is a growing body of evidence suggesting that domestic abuse (DA) should be conceptualised within the complex post‐traumatic stress disorder (C‐PTSD) model. Recently, in the draft of the International Classification of Diseases, Eleventh Revision, produced by the World Health Organization (WHO), C‐PTSD was included as a separate criterion in which DA is incorporated (ICD‐11, WHO, 2018). In this study, a thematic analysis was used to explore to what extent practitioners working with DA survivors are familiar with PTSD and C‐PTSD. Research into such a prevalent and detrimental problem as DA is important to understand whether the development of theoretical knowledge about DA and C‐PTSD is addressed in practice. In a Women's Centre in South London, six semi‐structured interviews with middle‐aged female practitioners were conducted to investigate each counsellor's experiences, knowledge and reflections. Six final themes were constructed to summarise the main results. The findings demonstrate limited practitioner understanding of DA in terms of C‐PTSD, which seems to impact not only the effectiveness of treatment plans with DA survivors, but also counsellors’ own psychological and physical states. It is also indicated that DA can be conceptualised within the C‐PTSD model that corresponds with previous literature indicating the complex nature of DA. The overall results of the current research acknowledge that DA sectors should not be neglected and better funding and effective psychoeducation in this field are needed.     

Life‐events and post‐traumatic stress in a sample of English adolescents

The aim of the present study was to investigate the lifetime prevalence of negative life‐events and their association with post‐traumatic stress in English adolescents. Of the 427 adolescents surveyed, 360 (84%) endorsed at least one negative event. Respondents were asked to complete the Impact of Event Scale (IES: Horowitz, Wilner and Alvarez, 1979) for each event that they endorsed. For boys, highest levels of post‐traumatic stress were found in those who had experience of a ‘family member with a drink or drugs problem’, followed by ‘parental separation or divorce’, ‘life threat to family member’, and ‘life‐threat to self ’. For girls, highest levels of post‐traumatic stress were found in those who had experienced ‘attack or physical assault to self ’, followed by ‘family member with drink or drugs problem’, ‘parental separation or divorce’, and ‘life threat to family member’. These data suggest that moderate levels of post‐traumatic stress are present in around one fifth of adolescents who have experienced one of these events and that community levels of post‐traumatic stress in adolescents may be higher than previously thought. Copyright © 2000 John Wiley & Sons, Ltd.     

Emotional Processing Therapy for post traumatic stress disorder

While prolonged exposure is considered one of the “gold standard” and recommended treatments for post traumatic stress disorder (PTSD), it has been poorly utilised in clinical practice. Individuals with PTSD often find it too distressing to confront memories, and therapists may be uncomfortable using the therapy. A new Emotional Processing Therapy is described in which an emotional approach to prolonged exposure provides individuals with a new insight into how trauma is processed. A conceptual analysis of exposure suggests that it is exposure to distressing emotional experiences which is a key element. Viewing it as an emotion-based therapy, allows the creative addition of new emotional elements. Through exploring the individual’s emotional processing style, previously learned and unhelpful patterns can be addressed, and the addition of an “emotional preparation” phase helps them understand why it is important to face emotionally distressing memories before exposure sessions begin. Emotional Processing Therapy is intuitive and makes sense to those affected by PTSD. It is framed in an emotional context and is presented as part of a lifestyle change that may reduce the likelihood of psychological problems developing in the future.     

First‐line therapy for post‐traumatic stress disorder: A systematic review of cognitive behavioural therapy and psychodynamic approaches

Background

Despite evidence supporting cognitive behavioural therapy (CBT)‐based interventions as the most effective approach for treating post‐traumatic stress disorder (PTSD) in randomised control trials, alternative treatment interventions are often used in clinical practice. Psychodynamic (PDT)‐based interventions are one example of such preferred approaches, this is despite comparatively limited available evidence supporting their effectiveness for treating PTSD.

Aims

Existing research exploring effective therapeutic interventions for PTSD includes trauma‐focused CBT involving exposure techniques. The present review sought to establish the treatment efficacy of CBT and PDT approaches and considers the potential impact of selecting PDT‐based techniques over CBT‐based techniques for the treatment of PTSD.

Results

The evidence reviewed provided examples supporting PDT‐based therapy as an effective treatment for PTSD, but confirmed CBT as more effective in the treatment of this particular disorder. Comparable dropout rates were reported for both treatment approaches, suggesting that relative dropout rate should not be a pivotal factor in the selection of a PDT approach over CBT for treatment of PTSD.

Conclusion/Implications

The need to routinely observe evidence‐based recommendations for effective treatment of PTSD is highlighted and factors undermining practitioner engagement with CBT‐based interventions for the treatment of PTSD are identified.     

The effects of torture‐related stressors on long‐term complex post‐traumatic symptoms in South Korean torture survivors

This study explored whether perceived distress from specific stressors during and after torture explain long‐term complex post‐traumatic symptoms of South Korean torture survivors. We conducted a cross‐sectional survey of survivors who had been tortured by the homeland regime from the 1970s to the 2000s. Data from 206 survivors were gathered by key informants using target sampling and snowballing techniques. Project staff designed scales to encompass the specific types of stressors related to torture techniques used in Korea. Frequencies and distress ratings of exposure to torture, post‐torture psychosocial stressors and physical damage related to torture were gathered. Psychological symptoms were assessed by the Impact of Event Scale‐Revised‐Korean version and subscales of the Symptom Checklist 90‐Revised‐Korean version. Perceived distress from torture stressors was mainly divided into factors representing physical, psychological and deprivation torture by adapting a principal axis factor analysis. Hierarchical regression analyses showed that distress from psychological torture explained post‐traumatic stress disorder (PTSD) and that distress from deprivation explained PTSD and anxiety after controlling for demographic variables, psychological preparedness, time span since torture and distress from trauma other than torture. Among post‐torture stressors, distress from physical damage related to torture and social exclusion were strong indicators of complex symptoms.     

Systemic psychotherapy as an intervention for post‐traumatic stress responses: an introduction,theoretical rationale and overview of developments in an emerging field of interest

The purpose of this article is to critically examine the literature to provide a rationale for including systemic family therapy (SFT) in the psycho‐social treatment of people suffering the impact of post‐traumatic stress (PTS). Attention is drawn to the relatively underdeveloped academic literature on PTS and the family. The impact of PTS is conceptualized within a psycho‐social framework and the current evidence base for psycho‐social interventions for PTS responses is described, highlighting the opportunity and need to undergird this area of daily practice. The impact of PTS on the family at multiple levels is identified, emphasizing its recursive nature. The case for SFT is articulated and a range of models of family intervention for PTS briefly reviewed, concluding with an emphasis on Walsh's key processes in family resilience as a framework for practice.     

Post–traumatic stress disorder in patients with coronary artery disease: A review and evaluation of the risk

Psychosocial factors are known to impact on the prognosis of patients with coronary artery disease independently of disease severity. However, few studies have looked at whether these patients are at risk of developing post-traumatic stress disorder, and the potential implications for morbidity and mortality. Through a review of the empirical literature, the objectives were to investigate whether patients with coronary artery disease are at risk of developing this disorder, to look at relations between post-traumatic stress disorder and heart disease, and to stimulate further research. The review indicated that some patients with coronary artery disease are at risk of developing post-traumatic stress disorder, although the prevalence varied considerably. Methodological issues together with recommendations for future research are discussed. Although only some cardiac patients may develop post-traumatic stress, this disorder should not be overlooked due to its potential role in reinfarctions and mortality.     

Characteristics of memories for traumatic and nontraumatic birth

Evidence for memory characteristic differences between trauma and other memories in non‐clinical samples is inconsistent. However, trauma is frequently confounded with the event recalled. This study compares trauma and nontrauma memories for the same event, childbirth, in a non‐clinical sample of 285 women 4–6 weeks after birth. None of the women met diagnostic criteria for post‐traumatic stress disorder. Traumatic birth, defined by the DSM‐5 event criterion, was reported by 100 women. The ratings of some memory characteristics did not differ between memories for traumatic and nontraumatic birth: All were rated highly coherent and central to women's lives, with moderate sensory memory. However, women who experienced traumatic births reported more involuntary recall, reliving, and negative/mixed emotions. Thus, trauma memories differed from nontrauma memories. In this non‐clinical sample, this is likely to be due to encoding during trauma rather than the distinctive memory profile for memories retrieved by those experiencing trauma symptoms.     

Interactive effects of cumulative lifetime traumatic brain injuries and combat exposure on posttraumatic stress among deployed military personnel

Growing research links Traumatic Brain Injury (TBI) with greater posttraumatic stress disorder (PTSD) symptoms. Much of this research has focused on the influence of the presence or severity of a single TBI while neglecting the potential cumulative effects of multiple TBIs incurred across an individual’s lifetime on combat-related PTSD. The present study addressed this gap using a sample of 157 military service members and 4 civilian contractors who underwent structured TBI interviews at a military hospital in Iraq and completed the Combat Experiences Scale (CES) and Posttraumatic Checklist – Military (PCL-M). Results indicated that a greater number of lifetime TBIs were associated with greater PTSD symptoms when accounting for the presence and severity of a recent, deployment-related TBI. Additionally, a significant interaction of number of lifetime TBIs and combat exposure emerged, indicating that exposure to combat yielded greater PTSD symptoms among those with multiple lifetime TBIs compared to those with one or zero lifetime TBIs. These data suggest that incurring multiple TBIs may amplify the link between combat exposure and PTSD and underscore the need to screen for lifetime TBI history.     

Changes in personality in pre‐ and post‐dialectical behaviour therapy borderline personality disorder groups: A question of self‐control

Dialectical behaviour therapy (DBT) is an evidence‐based therapy for people with borderline personality disorder (BPD). Past research has identified behavioural changes indicating improved functioning for people who undergo DBT. To date, however, there has been little research investigating the underlying mechanism of change. The present study utilised a between‐subjects design and self‐report questionnaires of Self‐Control and the five factor model of personality and drew participants from a metropolitan DBT program. We found that pre‐treatment participants were significantly lower on Self‐Control, Agreeableness and Conscientiousness when compared to both the post‐treatment assessment and the norms for each questionnaire. Neuroticism was significantly higher both before and after treatment when compared to the norms. These findings suggest that Self‐Control may play a role in both the presentation of this disorder and the effect of DBT. High levels of Neuroticism lend weight to the Linehan biosocial model of BPD development.     

Unemployment in Iraqi refugees: The interaction of pre and post‐displacement trauma

Previous refugee research has been unable to link pre‐displacement trauma with unemployment in the host country. The current study assessed the role of pre‐displacement trauma, post‐displacement trauma, and the interaction of both trauma types to prospectively examine unemployment in a random sample of newly‐arrived Iraqi refugees. Participants (N = 286) were interviewed three times over the first two years post‐arrival. Refugees were assessed for pre‐displacement trauma exposure, post‐displacement trauma exposure, a history of unemployment in the country of origin and host country, and symptoms of posttraumatic stress disorder (PTSD) and depression. Analyses found that neither pre‐displacement nor post‐displacement trauma independently predicted unemployment 2 years post‐arrival; however, the interaction of pre and post‐displacement trauma predicted 2‐year unemployment. Refugees with high levels of both pre and post‐displacement trauma had a 91% predicted probability of unemployment, whereas those with low levels of both traumas had a 20% predicted probability. This interaction remained significant after controlling for sociodemographic variables and mental health upon arrival to the US. Resettlement agencies and community organizations should consider the interactive effect of encountering additional trauma after escaping the hardships of the refugee's country of origin.     

Trauma‐focused CBT with maltreated children: A clinic‐based evaluation of a new treatment manual

The effectiveness of a locally developed trauma‐focused cognitive behavioural therapy (TF‐CBT) program for maltreated children with post‐traumatic stress disorder (PTSD) was examined across different therapists in a child protection clinic setting. An earlier phase of the research piloting the program had provided promising results. This second phase involved two studies evaluating the completed TF‐CBT manual delivered by (a) the developer and (b) other therapists. A single‐case multiple‐baseline design was used to demonstrate the controlling effects of the treatment on PTSD symptoms and child coping. Eight 9–13‐year‐old abused children with PTSD were treated. Positive outcomes support the effectiveness of the TF‐CBT program delivered by both the developer and other therapists. The study design and methodology were robust enough to confirm empirically the clinically beneficial effects and potential for this new program. It was also apparent, however, from study limitations, including missing data for some patients, that there are a number of challenges in carrying out such research in a busy child protection service setting with multiply‐abused patients. This paper considers implications and ways forward for engaging in empirically supported practice as well as future development and research.     

The Political Consequences of Combat: Post‐Traumatic Stress and Political Alienation Among Vietnam Veterans

On average, veterans are more civically and politically engaged than civilians. Previous research on the effects of military service, however, did not account for differences in veterans’ combat experiences. Using survey data from a representative sample of Vietnam veterans, this study presents evidence that veterans who were exposed to severe combat trauma and veterans who exhibited attitudes and fears associated with post‐traumatic stress had significantly lower levels of political efficacy and trust. The negative consequences of combat exposure and post‐traumatic stress are not mitigated when veterans have quality social support or when they seek professional counseling. These findings inform political psychology and hold implications for claims regarding the empowering influence of service in the U.S. military, increased political engagement, in particular. Among Vietnam veterans, exposure to severe combat trauma and post‐traumatic stress were both associated with reduced political efficacy and trust.     

The concept of psychical trauma: A bridge in interdisciplinary space1

The concept of trauma currently occupies a central position in interdisciplinary dialogue. Using the concept of psychical trauma as a bridge, the author attempts an interdisciplinary dialogue with psychiatry, biology and neuroscience. Beginning with the concept of psychical trauma in Freud, the author reviews the evolution of Freud's thinking, and links it with the ideas of Ferenczi and post‐Freudian psychoanalytical authors. From a different framework, he considers the present state of research on post‐traumatic stress disorder in current psychiatric nosography and attempts an interdisciplinary approximation to the concept of psychical trauma. Interesting ideas like the traumatic situation, trauma spectrum and psychopathological spectrum emerge, which enable a better understanding of the concept of psychical trauma through its relatedness, as a bridge connecting a broad psychopathological range extending from normality to psychosis. The ensuing possible relative loss of nosographical rigour is more than compensated by the resulting increased understanding and enlarged therapeutic possibilities. In the second part of the paper, the author attempts a dialogue with neuroscience, taking into account new advances in current research on emotion and memory, and making them compatible with the psychoanalytical concept of trauma. In this sense, the paper underlines the importance of emotion and crucially of memory, regarded as a fundamental axis of the subject explored in this paper. Here a substantial distinction which is pertinent for analytical work appears: declarative memories versus non‐declarative or procedural memories. In a concluding discussion the author argues that, taking into account the implications of these current notions regarding a number of theoretical and technical aspects, psychoanalysis currently holds a privileged position, both in its potential for prevention and regarding the treatment of patients, in so far as, through interdisciplinary dialogue, psychoanalysis can be receptive to and be enriched by the contributions of other disciplines, just as it enriches them with its own contributions.